Home states and Job Families Top 10 States of employees State # of employees California 6,810 Florida 3,835 Pennsylvania 3,162 Texas 3,082 New Jersey 2,571 Virginia 2,080 Missouri 1,654 North Carolina 1,558 Kansas 1,553 Georgia 1,515 Top Job Families Job Family # of employees Patient Services 13,520 Technical Lab Services 6,885 Logistics/Couriers 4,066 Specimen Processors 3,367 Billing 2,380 Client Services 2,190 Laboratory Support 1,839 Sales 1,715 Information Tech. 1,498 Laboratory Mgt 1,047

: 7 February 3, 2016

Objectives/Background 9 February 3, 2016

Institute of Medicine. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press; 2006

Center for Disease Control and Prevention. Unhealthly Sleep Related Behaviors; Morbidity & Mortality Weekly Report; March 4 th, 2011

Many large studies have found a relationship between sleepiness and work-related injuries. Highly sleepy workers are 70 percent more likely to be involved in accidents than nonsleepy workers, and workers with chronic insomnia (difficulty getting to or staying asleep) are far more likely than wellrested individuals to report industrial accidents or injuries. https://sleepfoundation.org/excessivesleepiness/content/the-relationship-between-sleep-and-industrial-accidents

Slightly over 2 hours of additional sleep can cut the injury rate 3-fold* *ACOEM Presidential Task Force. ACOEM Guidance Statement: Fatigue Risk Management in the Workplace; Journal of Occupational & Environmental Medicine; February, 2012

Resident Duty Hours, Enhancing Sleep and Safety. Institute of Medicine, National Academy of Sciences Report, 2003.

Date of download: 1/4/2016 Copyright American College of Chest Physicians. All rights reserved. Increased Physician-Reported Sleep Apnea * : The National Ambulatory Medical Care Survey Figure Legend: NAMCS reports of sleep disorders (from 1990 to 1998). Over a 9-year period, there was a fourfold increase (p < 0.0001) in physicianreported insomnia, while a 12-fold increase was observed among reports of sleep apnea. No significant increase was shown in reported narcolepsy, restless legs syndrome, and parasomnias. Chest. 2002;121(6):1741-1747. doi:10.1378/chest.121.6.1741

Sleep disorders are associated with higher medical costs Individuals with sleep-related conditions have approximately 3 times the annual medical costs of the overall population Member with sleep-related conditions Total population $3,259 $1,142 PMPY cost Annual employee OOP cost MERCER Source: Mercer Focus/Mercer Health Online data 11/2010 10/2011 February 3, 2016 18

Treating OSA: $2,727 57% Y1 Medical Plan Cost Reduction Risk of Stroke Reduction 20 million Americans have Obstructive Sleep Apnea (OSA) and 85% remain undiagnosed Employers spend $3,200-$4,000 in incremental annual healthcare dollars on employees with unmanaged OSA Sleep and fatigue are two of the top three cost drivers for both presenteeism and absenteeism MERCER

Berlin Questionnaire administered as part of the HRA for EEs and spouses in 2014 8,350 unique respondents were identified as meeting the Berlin Questionnaire criteria for risk for sleep apnea 5,223 identified as Aetna members at the time (Target Population) 2,035 identified as non-aetna members 1,092 unidentified (no SSN or no longer eligible) The Target Population was stratified into two Groups Group A Berlin at Risk w/ Comorbid Conditions (as per Aetna's CPB) 483 members Letter mailed 7/1 Group B Berlin at Risk-remaining members 4,740 members Letter mailed 8/29

Prevalence of OSA All Members OSA Claimants Adult Prevalence All Members Plan Year 2014 390 0.9% All Members Plan Year 2015 467 1.0% Period Prevalence '13-15 (unique members) 547 2.3% Prevalence of OSA Berlin@Risk Members January 2014 through July 2015 530 10% OSA claims Group A (Berlin@Risk+ Comorbid) 109 23% OSA claims Group B Berlin@Risk 421 9% With a nearly 5-fold difference in prevalence of OSA, the Berlin survey enhancement to the HRA appears to be identifying the right members for intervention

OSA Metrics Total Population Berlin@Risk Population Pre-Letter Measurements Aug - Nov 2014 Jan 2014 - July 2015 Unique OSA Claimants Per 1,000 15.6 72.5 Sleep related Office Visits Per 1,000 34.5 402.5 OSA Metrics Total Population Berlin@Risk Population Post Letter Measurements Aug - Nov 2015 Aug - Nov 2015 Unique OSA Claimants Per 1,000 16.8 181.6 Sleep related Office Visits Per 1,000 41.5 448.5 Change in Metrics Total Population Berlin@Risk Population Unique Claimants Per 1,000 7% increase 150% increase Sleep related Visits Per 1,000 20% increase 11% increase --New cases of OSA and engagement with the healthcare system increased in both the intervention group and the overall population after the communication letters were mailed to 5,223 at-risk members

Pre-Intervention Analysis Claims from 8/1/2014-7/31/2015 92 members had claims related to sleep 46 members received CPAP machines 24 members had sleep studies 59 received supplies 34 members had office visits 1 member had claims for a wakefulness drug Post-Intervention Analysis Claims from 8/1/2015 to 11/30/2015 53 of the members had claims related to sleep apnea (11%) 8 of the 53 members have no evidence of claims in the prior 12 months for sleep apnea (1.6%) Sleep studies, CPAP, etc.

Pre-Intervention Analysis Claims from 10/1/2014-9/30/2015 375 members had claims related to sleep apnea in the 12 months prior to the mailing 123 members had sleep studies 174 members received CPAP machines 335 members received supplies 160 members had office visits 8 member had claims for a wakefulness drug Pot Intervention Analysis Claims from 10/1/2015 to 11/30/2015 168 of the members had claims related to sleep apnea (3.5%) 40 of the 168 members have no evidence of claims in the prior 12 months for sleep apnea (0.8%) Sleep studies, CPAP, etc.

When the impact time period (August-November 2015) of the July 2015 OSA intervention is compared with the same time period in 2014 through incidence rate (new cases of OSA in Berlin@Riskers), there is a 34% increase in new cases of OSA Aug., 2014-Nov., 2014 Incidence Rate of OSA Aug, 2015-Nov., 2015 Incidence Rate of OSA 38.9 Number of new cases (no evidence in prior 12 month period) / MM * 12000 52.2 Number of new cases (no evidence in prior 12 month period) / MM * 12000

Sleep Survey Population # Work Comp Claims WC Incidence Rate No Risk Berlin 24,914 299 1.2% At Risk Berlin 8,361 127 1.5%